Avoidance of estrogen caused excess deaths in hysterectomized women

After publication of the Women's Health Initiative (WHI), estrogen use declined significantly among women aged 50 to 59, likely resulting in avoidable deaths of those who had hysterectomies, a recent analysis found.

Estrogen reduces overall mortality primarily through a reduction in coronary heart disease-related deaths, and estrogen-only therapy had previously been routinely prescribed for women in their 50s who had undergone a hysterectomy to optimize its beneficial effect on mortality. However, following publication of the WHI study, the use of hormone therapy declined precipitously among postmenopausal women, including the use of estrogen-only treatment in women in their 50s who had undergone hysterectomy despite subsequent research that showed a mortality benefit to estrogen treatment in this patient group. This raised the concern that decreased estrogen treatment in this group of women might lead to increased mortality.

Researchers combined data from the WHI, the U.S. Census, the National Hospital Discharge Survey and several recent studies of estrogen use to make their calculations. The WHI Estrogen-Alone Trial showed an increased mortality rate of 13 per 10,000 women per year when a placebo, instead of estrogen, was given to women between ages 50 and 59 who had a hysterectomy. The census and the National Hospital Discharge Survey provided annual estimates of this population, and previously published studies showed that use of oral estrogen alone dropped steadily after 2001. For example, before the WHI publication, about 90% of women having both a hysterectomy and oophorectomy took estrogen therapy, compared to only about a third today, the researchers reported.

Based on these figures, a minimum of 18,601 women in this group (ages 50 to 59, with a hysterectomy) died prematurely between 2002 and 2011 due to their failure to take estrogen, the researchers calculated. When higher estimates of hysterectomy and mortality rates are used, as many as 91,610 women may have died prematurely during that period due to the avoidance of estrogen therapy, they concluded. Results were published by American Journal of Public Health on July 18.

The findings show the urgent need for informed discussion among women and clinicians about the actual findings of the WHI, the authors said. Women's decisions to avoid estrogen therapy have been influenced by clinicians' and the media's failures to differentiate among the various findings on the harms and benefits of estrogen therapy, particularly for specific groups of women who might benefit from treatment. Women in their 50s who have had hysterectomies, in particular, need accurate information about the potential benefits to their health, the authors concluded.